I am honored to present the third annual Memorial Lecture to commemorate the achievements of the late Marian W. Fischman. Marian was a dedicated and creative scientist and an effective science advocate. She was also an outstanding mentor and very supportive of her trainees and junior collaborators. And Marian was a wonderful colleague and a delightful person to be with. All of us who knew her continue to mourn her loss.
This study evaluated the benefits of a brief training and treatment-services matching technology designed to give clinical meaning and value to a research-based assessment, and thereby improve treatment planning and services matching. The study used the Addiction Severity Index (ASI) as the assessment. Data were analyzed from 95 patients of 26 counselors in 8 treatment programs, randomly assigned to one of two conditions. Standard Assessment Training (ST) included a two-day training course on the use of a computer-assisted ASI interview. Enhanced Assessment and Treatment Care Planning Training (ET) also used exactly the same computer-assisted ASI training. but added 2 hours of training on how to use the new technology; a computer Resource Guide (RG) to free or low-cost “wrap-around” (e.g. medical, employment, legal, housing, psychiatric) services. This training was expected to provide the counselors with a concrete method of using the ASI information to develop better treatment plans at admission and to access more comprehensive services for their patients. Both groups were equally likely to complete the ASI training and showed comparable scores on ASI competency measures. Patients in the ET group had substantially better-matched treatment plans (patient problems to plans for treatment), and received significantly increased and better-matched services than patients in the ST group.
ObjectiveThe purpose of this study was to examine the effectiveness of counseling to promote a healthy diet among patients in primary care settings.Design and data sourcesWe conducted a MEDLINE search from 1966 to December 2001.Study selectionWe included randomized controlled trials of at least 3 months' duration with measures of dietary behavior that were conducted in patient populations similar to those found in primary care practices. We excluded studies that reported only biochemical or anthropomorphic endpoints, had dropout rates greater than 50%, or enrolled patients based on the presence of a chronic disease.Data extractionOne author extracted relevant data from each included article into evidence tables. Using definitions developed by the research team, two authors independently rated each study in terms of its effect size, the intensity of its intervention, the patient risk level, and the use of well-proven counseling techniques.Data synthesisWe identified 21 trials for use in this review. Dietary counseling produces modest changes in self-reported consumption of saturated fat, fruits and vegetables, and possibly dietary fiber. More-intensive interventions were more likely to produce important changes than brief interventions, but they may be more difficult to apply to typical primary care patients. Interventions using interactive health communications, including computer-generated telephone or mail messages, can also produce moderate dietary changes.ConclusionsModerate- or high-intensity counseling interventions, including use of interactive health communication tools, can reduce consumption of saturated fat and increase intake of fruit and vegetable. Brief counseling of unselected patients by primary care providers appears to produce small changes in dietary behavior, but its effect on health outcomes is unclear.
ii ACKNOWLEDGMENT This monograph is based on the papers from a technical review " Laboratory Behavioral Studies of Vulnerability to Drug Abuse " held on August 2-3, 1994. The review meeting was sponsored by the National Institute on Drug Abuse. The National Institute on Drug Abuse has obtained permission from the copyright holders to reproduce certain previously published material as noted in the text. Further reproduction of this copyrighted material is permitted only as part of a reprinting of the entire publication or chapter. For any other use, the copyright holder's permission is required. All other material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated. Opinions expressed in this volume are those of the authors and do not necessarily reflect the opinions or official policy of the National Institute on Drug Abuse or any other part of the U.S. Department of Health and Human Services. The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this publication are used only because they are considered essential in the context of the studies reported herein.
In nonlaboratory settings, social users of cocaine are sometimes able to control their drug intake so their patterns of use do not escalate to levels that would increase their risk of dependency and toxicity (Siegel 1984). This suggests that there may be factors in addition to the primary reinforcing properties of cocaine that determine why some individuals can remain casual recreational users while others progress to compulsive drug use. Individual reactivity to anxiety or stress, either mitigated or induced by cocaine, may represent one such factor that could influence the awareness or perception of the reinforcing efficacy of the drug. Clinical evidence supports the concept that anxiety may be involved in the etiology of cocaine use and/or withdrawal. For example, initial cocaine use produces profound subjective feelings of well-being and a decrease in anxiety in humans (Gawin and Ellinwood 1988, 1989). Interestingly, some of the major symptoms observed during withdrawal from chronic cocaine intoxication can also include severe anxiety as well as restlessness, agitation, and depression (Gawin and Ellinwood 1989). In fact, a subpopulation of chronic cocaine users may actually be self-medicating to regulate painful feelings and psychiatric symptoms via their drug use (Gawin 1986; Khantzian 1985; Kleber and Gawin 1984), especially since increased rates of affective disorders and anxiety are observed in these individuals (Brady and Lydiard 1992; Kilbey et al. 1992; Rounsaville et al. 1991). Cocaine has even been reported to precipitate episodes of panic attack in some individuals (Anthony et al. 1989; Aronson and Craig 1986; Washton and Gold 1984). Since panic disorder only became apparent following chronic cocaine use in many of these cases, the drug may have functioned as a precipitating as well as a causative factor in a neurobiologically vulnerable individual (Aronson and Craig 1986). Since environmental events can also influence the onset and/or duration of anxiety and depression (Brown et al. 1973; Leff et al. 1970; Lloyd 1980), changes in the amount, severity, or perception of environmental stress may actually predispose sensitive individuals to engage in compulsive drug use.
It is known that individuals differ in their likelihood of becoming drug abusers. Many people never take any drugs at all, even on a single occasion. Of those who take drugs at least once, only a small number go on to use the drugs on a regular basis, and even fewer go on to use them in excessive quantities or abusive patterns. The differences in numbers of individuals who have ever tried drugs and those who become regular users is roughly illustrated by data from a national household survey (National Institute on Drug Abuse 1992): 37 percent of U.S. adults reported having used an illicit drug at least once in their lives, while only 6.3 percent report having used an illicit drug in the past month. “Illicit drug” here includes marijuana, nonmedical use of psychotherapeutics, inhalants, cocaine, hallucinogens, or heroin. Similarly, in 1993, 43 percent of U.S. high school students reported having tried an illicit drug at least once in their lives, while only 18 percent used any drugs in the past month (National Institute on Drug Abuse 1994). Many individuals limit their use to an initial sampling of the drug. Other individuals become occasional users, but use the drugs in moderation without developing any problems of abuse or dependence. However, a small but significant proportion of young individuals appears to progress rather rapidly (i.e., in their late teens and early twenties) to excessive use, and continue to use drugs despite harmful consequences. Why some individuals and not others are susceptible to drug or alcohol abuse is unclear. Some researchers have investigated risk factors through epidemiological or longitudinal studies designed to detect predictors and correlates of heavy drug use (see Tarter, this volume). Other researchers have used laboratorybased procedures to investigate individual differences in acute responses to drugs. This chapter will focus on a series of studies that used the latter approach to examine individual differences in response to acute doses of benzodiazepines.
A great deal of research has focused on initiation into drug use and factors that increase the risk of initiation or protect against it. Initiation into the use of some drugs (such as alcohol) is extremely common, whereas initiation into use of other drugs (such as cocaine) is less frequent (Kandel 1975). Regardless of initiation rate, most individuals who try a particular drug do not continue into a pattern of abuse, although different substances appear to differ in their abuse potential. For example, many adults in the United States can be considered “social” drinkers, but a much smaller percentage are considered “problem” drinkers. The abuse potential of cocaine is considered to be much higher among those individuals who continue to use on a regular basis. Newcomb (1992) found that about 15 percent of young adult alcohol users had developed a pattern of dependency, whereas about one-third of those who had used cocaine within the previous 6 months showed a pattern of dependency. Thus, different substances appear to differ in abuse potential, but, in addition, different individuals also vary in their vulnerability to abuse. A wide variety of psychological and social factors contribute to this variability; the purpose of this chapter is to present a series of animal studies, and more limited human data, which suggest one biological model that may explain differing responses to cocaine. Different individuals, as a result of previous exposure to other stimulants, may initially experience cocaine as more (or less) positive; these different responses will influence the likelihood of continuing to take cocaine and the timecourse for the development of a pattern of abuse.
Epidemiological research has clearly demonstrated the importance of a family history as a determinant of future alcohol and, possibly, drug use in offspring of alcoholics. Laboratory studies have examined a wide range of potential markers both in the presence and absence of alcohol challenge, which may predict those subjects at high risk for the future development of alcoholism. While this body of research has yielded several replicable differences in FHP and FHN subjects, it also has been marked by many discrepancies in outcomes across studies. Future refinements in subject ascertainment and laboratory methodologies may help to bring greater procedural uniformity and consistency in study outcomes.
Animal models of drug self-administration have been shown to be valid predictors of human drug abuse (Griffiths et al. 1980; Johanson 1978; Johanson and Schuster 1981; Spealman and Goldberg 1978; Woolverton and Nader 1990). In drug self-administration studies, if responding leading to the presentation of the drug occurs at higher rates than vehicle-maintained responding, then the drug is said to function as a positive reinforcer and have abuse liability. The focus of the research described in this chapter will be to examine the interactions of several environmental and pharmacological variables with the reinforcing effects of cocaine in rhesus monkeys, with emphasis on the long-term effects of these experimental histories. One of the goals of this chapter will be to address technical or methodological issues regarding animal models of drug selfadministration. To this end, published data as well as preliminary data will be presented. Although the scientific community urges the presentation of group data, most animal experiments in behavioral pharmacology are conducted on an individual-subject basis. Consequently, to highlight further the methodological issues regarding the influence of environmental and pharmacological variables in modifying cocaine self-administration, most of the data presented will be individual-subject data, rather than group data.
Several observations suggest that there may be specific, important relationships between taste/diet preferences and drug selfadministration. These include reports of: (a) differences in drug selfadministration in rats with differing baseline taste or diet preferences, (b) correlations between the intake of saccharin and the intake of alcohol, and (c) changes in drug self-administration when sweettasting solutions are provided as alternative reinforcers. In humans, there is a high comorbidity between eating disorders and drug and alcohol abuse. Further, this relationship extends to subclinical levels of each behavior. With a better under-standing of these relationships, it may be possible to use measures of diet and taste preferences, along with dietary manipulations, to predict and reduce vulnerability to drug abuse, as well as to monitor and improve current treatments for drug abuse. Animal and human studies relevant to the relationship between diet and taste preferences and drug abuse will be reviewed below, followed by a brief discussion of the possible mechanism underlying the relationship.
Addictive behavior with respect to drugs often is viewed as the consequence of a biologic action that has its principal origin in the exposure of a subject to the central nervous action of a drug. One objective of this chapter is to refer briefly to evidence that drug abuse is a special case of excessive behavior that typically develops out of, and is sustained by, an antecedent context that can generate a variety of disturbed and excessive sorts of behavior. Drug abuse is often only one feature of this broader picture of behavioral difficulties displayed by an afflicted individual. Conversely then, by this view drug addiction has its major origins and maintaining conditions in environmental antecedents, rather than being the result of specific drug receptor interactive consequences.
